Provider Demographics
NPI:1639482771
Name:BULL, LISA RUBIN (SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RUBIN
Last Name:BULL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 TALLYRAND CT
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2700
Mailing Address - Country:US
Mailing Address - Phone:703-925-0118
Mailing Address - Fax:703-925-0118
Practice Address - Street 1:1604 SPRING HILL RD
Practice Address - Street 2:SUITE 310
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-7510
Practice Address - Country:US
Practice Address - Phone:703-546-8594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202002478235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist